Proposal / Qualification and Costs Submission Form

PROFESSIONAL SERVICE CONTRACT

PROPOSAL / QUALIFICATION AND COSTS SUBMISSION FORM

Please provide the name and address of Submitting Firm, Individual or Entity:

______

Please indicate the Professional Service/ Title for which you are Submitting:

______

Please State the Name and address of specific City, Authority, Board or other Public

Body to which you are responding:

______

Note: In responding to these questions you may attach additional sheets as

necessary. Please be sure to CLEARLY reference all additional sheets or relevant attachments under the appropriate question or area. Material not clearly referenced

will not be considered.

1. Is your firm willing and able to perform the scope of services set forth in the

Notice of Solicitation for Professional Services and the Solicitation Package for

the above Professional Service / Title?

2. If the answer to question 1 is "No", then please explain any exceptions,

clarifications or limitations to the scope of services that your firm is willing and

able to provide?

Professional Service PROPOSAL / QUALIFICATION AND COSTS SUBMISSION FORM

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3. Please provide the names and roles of the individuals who will perform the

services, descriptions of their education and experience, degrees, licenses and certifications relevant to those services including specific experience with the Client/Owner to whom this submission is being sent (or with similar Client/Owners).

4. Please discuss your (the firm's) record of success in providing the same or

similar services to those being requested.

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5. Please provide references who can be contacted to substantiate the

above noted experience or record of success for the same or similar service.

6. Please provide a list of your current municipal or public clients as well as past

municipal clients.

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7. Please describe your (the firm's) ability to provide the services in a timely fashion

(including staffing, familiarity and location of key staff, availability and/or

ownership of key resources). If appropriate, a description of technical process and equipment available to the organization and used in performing the task(s) within the scope of work that may be provided.

8. Please disclose any conflicts of interest you have or reasonably

anticipate having with respect to your firm's past, current or

pending representation of clients or entities who are engaged in

litigation or disputes with the Borough of Little Ferry or its associated entities

or who are appearing before or making application to its Boards or

Agencies. If none, state "none."

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Please provide a breakdown of costs for service (cost details), including the

hourly rates of each of the individuals who will be performing services

and a schedule of costs for reimbursable expenses and/or a budgeted

amount for reimbursable expenses. If all or any part of the work

proposed is to be performed on a lump sum or flat fee (as opposed to an

hourly or reimbursable basis) please provide the amount of that lump

sum or flat fee as well as specifically detailing the full scope of work to

be included under the proposed lump sum or flat fee. It is also

permissible to provide alternative fee proposals (lump sum or hourly) for

the same scope of work, but again, it is very important to clearly delineate what is included.

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10. (OPTIONAL) ADDITIONAL MATERIAL. Please discuss any relevant or

supplementary materials which may demonstrate your firm's qualification or capacity to perform the professional services listed or to illustrate why hiring

your firm to perform these services would be in the best interest of the Borough.

11. (OPTIONAL) EXTENDING TERM OF OFFER. All submissions must be held open

for 60 days following opening on the due date and then accepted or rejected unless a submitting party agrees to hold its offer open. Does your firm wish to hold your offer

open for a longer period (up to one year maximum)? If yes, state the maximum

length of time for which the offer made herein can be accepted by the Client/Owner.

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In completing and submitting this form the submitting firm, individual or entity

acknowledges that it has received and read the following which were provided with

the submission materials:

• The Notice of Solicitation for Professional Service, pertaining to the

Professional Title/Service which is the subject of this submission

• The "Title/ Service Description and Minimum Requirements" pertaining

to the above Professional Title/Service and any supplemental addendum.

• The "General Instructions, Submission and Selection Criteria"

• The "General Contract Requirements and Addendums A, B & C"

CHECKLIST. The following items, as indicated below, shall be provided

with the receipt of sealed submissions:

1. Professional Service Proposal, Qualifications and Costs Submission Form (This form)

must be signed and dated. Please be sure to CLEARLY reference all additional

sheets and attachments ______

2. Non-Collusion Affidavit - must be signed and Notarized.. ______

3. Disclosure of Ownership Form - must be signed.______4. Professional Service Entity Information Form ... ______

5. Copy of your Business Registration Certificate as issued by the State of New

Jersey Department of Treasury, Division of Revenue ... ______

6. Mandatory Equal Employment Opportunity Notice Acknowledgement……______

I certify that I am an authorized representative of the firm or business named below and offer

on behalf of the firm to provide the professional services set forth herein in accordance with this submission form and the terms of the solicitation and submission materials noted above. I further certify that the information contained in and attached to this submission is true to the best of my knowledge and belief, with the understanding that it will be relied upon as such by the public entity to which it is being submitted.

Firm: ______Date: ______

Firm Name (Print or Type):

BY:

Authorized Representative ______

Signature

Authorized Representative ______

Print Name Print Title

Telephone #: ______Fax #: ______

E-Mail ______

Professional Service PROPOSAL / QUALIFICATION AND COSTS SUBMISSION FORM

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NON‐COLLUSIONAFFIDAVIT

STATE OF NEW JERSEY :

: SS.

COUNTY OF ______:

I, ______of ______

Name of Affiant (Affiant's Town, City, Borough or Municipality)

in the County of ______and the State of ______, of full age,

(Affiant's County) (Affiant's State)

being duly sworn according to law on my oath depose and say that:

I am ______of the firm of ______

Affiant's Title in Submitting Company (Name of Submitting Professional Service Entity)

______,

(Address of Submitting Firm.)

the Professional Service Entity making the submission to provide professional services as

______to

(Professional Service / Title / Contract Being Applied For)

the ______(the "Client/Owner")

(Name of Municipal or Public Entity to which you are applying)

that I executed the enclosed documents and submissions with full authority to do so; that said Professional Service Entity has not, directly or indirectly, entered into any agreements, participated in any collusion, or otherwise taken any action in restraint of fair and open competition in connection with the submission to be awarded a contract to provide such above named Service; and that all statements contained in said submission and in this affidavit are true and correct, and made with full knowledge that the Client/Owner has and will rely upon the truth of the statements contained in said submission and in the statements contained in this affidavit both in considering and making any awarding of a contract for said professional service.

I further warrant that no person or selling agency has been employed or retained to solicit

or secure such contract upon an agreement or understanding for a commission,

percentage, brokerage or contingent fee, except bona fide established commercial or

selling agencies maintained by ______.

(Name of Submitting Professional Service Entity )

Subscribed and sworn to before me

this ____ _ day of ____, 20___

______

Notary Public, State of ______

(Signature of Professional)

My Commission expires______

(Type or Print name of affiant and Title, under signature)

DISCLOSURE OF OWNERSHIP FORM

N.J.S.A. 52:25-24.2 reads in part that "no corporation or partnership shall be awarded any contract by the State, County, Municipality or School District, or any subsidiary or agency thereof, unless prior to the receipt of the submission of the corporation or partnership, there is provided to the public contracting unit a statement setting forth the names and addresses of all individual who own 10% or more of the stock or interest in the corporation or partnership".

If the professional service entity is a partnership, then the statement shall set forth the names and addresses of all partners who own a 10% or greater interest in the partnership.

If the professional service entity is a corporation, then the statement shall set forth the names and addresses of all stockholders in the corporation who own 10% or more of its stock of any class.

If a corporation owns all or part of the stock of the corporation or partnership providing the submission, then the statement shall include a list of the stockholders who own 10% or more of the stock of any class of that corporation.

If the professional service entity is other than a corporation or partnership, the contractor shall indicate the form of corporate ownership as listed below.

COMPLETE ONE OF THE FOLLOWING STATEMENTS:

I. Stockholders or Partners owning 10% or more of the company providing the

submission:

NAME: ADDRESS:

______

SIGNATURE: ______DATE: ______

II. No Stockholder or Partner owns 10% or more of the company providing this

submission:

SIGNATURE: ______DATE: ______

III. Submission is being provided by an individual who operates as a sole proprietorship:

SIGNATURE: ______DATE: ______

IV. Submission is being provided by a corporation or partnership that operates as a (check

one of the following):

______Limited Partnership ______Limited Liability Corporation

______Limited Liability Partnership ______Subchapter S Corporation

SIGNATURE: ______DATE: ______

PROFESSIONAL SERVICE ENTITY INFORMATION FORM

If the Professional Service Entity is an INDIVIDUAL, sign name and give the following information:

Name: ______

Address: ______

Telephone No.: ______Social Security No.:______

Fax No.: ______E-Mail: ______

If individual has a TRADE NAME, give such trade name:

Trading As: ______Telephone No.: ______

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If the Professional Service Entity is a PARTNERSHIP, give the following information:

Name of Partners: ______

Firm Name: ______

Address: ______

Telephone No.: ______Federal I.D. No.: ______

Fax No.: ______E-Mail: ______

Social Security No.: ______

Signature of authorized agent: ______

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If the Professional Service Entity is INCORPORATED, give the following information:

State under whose laws incorporated: ______

Location of principal office: ______

Telephone No.: ______Federal I.D. No.: ______

Fax No.: ______E-Mail: ______

Name of agent in charge of said office upon whom notice may be legally served:

______

Telephone No.: ______Name of Corporation: ______

Signature: By: ______

Title: Address: ______

MANDATORY EQUAL EMPLOYMENT OPPORTUNITY NOTICE

(N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 et seq.)

GOODS, PROFESSIONAL SERVICES AND GENERAL SERVICE CONTRACTS

This form is a summary of the successful professional service entity’s requirement to comply with

the requirements of N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 et seq.

The successful professional service entity shall submit to the Borough of Little Ferry, after

notification of award but prior to execution of this contract, one of the following three documents

as forms of evidence:

(a) A photocopy of a valid letter that the vendor is operating under an existing

Federally approved or sanctioned affirmative action program (good for one year from

the date of the letter);

(b) A photocopy of a Certificate of Employee Information Report approval,

issued in accordance with N.J.A.C. 17:27-1.1 et seq.;

the Division of Contract Compliance and distributed to the Borough of Little Ferry